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<h1 class="p_Heading1"><span class="f_Heading1">Universal Registration Form</span></h1>

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<p>One Registration for can be configured for the entire application. The idea is that this form is the universal registration for the facility. Different departments may have their own enrollment form which you would recreate as a dynamic form builder form.</p>
<p>&nbsp;</p>
<p>The pre-defined registration fields are saved in two different tables - mst_patient and dtl patientcontact. Any new custom fields you create will be placed in a new table called DTL_FBCUSTOMFIELD_Patient_Registration.</p>
<p>&nbsp;</p>
<p>There is a minimum set of fields that must be captured in order to register the patient into the system. </p>
<p>&nbsp;</p>
<p><img src="registrationform.png" width="650" height="268" alt="RegistrationForm" style="border:none" /></p>
<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="width:70%; border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:186px; background-color:#99ccff; padding:2px; border:solid 1px #000000;"><p><span style="font-weight: bold;">Display Label</span></p>
</td>
<td style="vertical-align:top; width:130px; background-color:#99ccff; padding:2px; border:solid 1px #000000;"><p><span style="font-weight: bold;">Display Type</span></p>
</td>
<td style="vertical-align:top; width:167px; background-color:#99ccff; padding:2px; border:solid 1px #000000;"><p><span style="font-weight: bold;">Table</span></p>
</td>
<td style="vertical-align:top; width:243px; background-color:#99ccff; padding:2px; border:solid 1px #000000;"><p><span style="font-weight: bold;">Field</span></p>
</td>
<td style="vertical-align:top; width:146px; background-color:#99ccff; padding:2px; border:solid 1px #000000;"><p><span style="font-weight: bold;">Required</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:186px; padding:2px; border:solid 1px #000000;"><p>Patient Name First</p>
</td>
<td style="vertical-align:top; width:130px; padding:2px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:167px; padding:2px; border:solid 1px #000000;"><p>mst_Patient</p>
</td>
<td style="vertical-align:top; width:243px; padding:2px; border:solid 1px #000000;"><p>FirstName</p>
</td>
<td style="vertical-align:top; width:146px; padding:2px; border:solid 1px #000000;"><p>Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:186px; padding:2px; border:solid 1px #000000;"><p>Patient Name Middle</p>
</td>
<td style="vertical-align:top; width:130px; padding:2px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:167px; padding:2px; border:solid 1px #000000;"><p>mst_Patient</p>
</td>
<td style="vertical-align:top; width:243px; padding:2px; border:solid 1px #000000;"><p>MiddelName</p>
</td>
<td style="vertical-align:top; width:146px; padding:2px; border:solid 1px #000000;"><br />
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:186px; padding:2px; border:solid 1px #000000;"><p>Patient Name Last</p>
</td>
<td style="vertical-align:top; width:130px; padding:2px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:167px; padding:2px; border:solid 1px #000000;"><p>mst_Patient</p>
</td>
<td style="vertical-align:top; width:243px; padding:2px; border:solid 1px #000000;"><p>LastName</p>
</td>
<td style="vertical-align:top; width:146px; padding:2px; border:solid 1px #000000;"><p>Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:186px; padding:2px; border:solid 1px #000000;"><p>Sex</p>
</td>
<td style="vertical-align:top; width:130px; padding:2px; border:solid 1px #000000;"><p>Select list</p>
</td>
<td style="vertical-align:top; width:167px; padding:2px; border:solid 1px #000000;"><p>mst_Patient</p>
</td>
<td style="vertical-align:top; width:243px; padding:2px; border:solid 1px #000000;"><p>Sex</p>
</td>
<td style="vertical-align:top; width:146px; padding:2px; border:solid 1px #000000;"><p>Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:186px; padding:2px; border:solid 1px #000000;"><p>Date of Birth</p>
</td>
<td style="vertical-align:top; width:130px; padding:2px; border:solid 1px #000000;"><p>Date</p>
</td>
<td style="vertical-align:top; width:167px; padding:2px; border:solid 1px #000000;"><p>mst_Patient</p>
</td>
<td style="vertical-align:top; width:243px; padding:2px; border:solid 1px #000000;"><p>DOB</p>
</td>
<td style="vertical-align:top; width:146px; padding:2px; border:solid 1px #000000;"><p>Yes</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:186px; padding:2px; border:solid 1px #000000;"><p>Exact, Estimated</p>
</td>
<td style="vertical-align:top; width:130px; padding:2px; border:solid 1px #000000;"><p>Radio</p>
</td>
<td style="vertical-align:top; width:167px; padding:2px; border:solid 1px #000000;"><p>mst_Patient</p>
</td>
<td style="vertical-align:top; width:243px; padding:2px; border:solid 1px #000000;"><p>DobPrecision</p>
</td>
<td style="vertical-align:top; width:146px; padding:2px; border:solid 1px #000000;"><br />
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:186px; padding:2px; border:solid 1px #000000;"><p>Age</p>
</td>
<td style="vertical-align:top; width:130px; padding:2px; border:solid 1px #000000;"><p>Calculated</p>
</td>
<td style="vertical-align:top; width:167px; padding:2px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:243px; padding:2px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:146px; padding:2px; border:solid 1px #000000;"><br />
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:186px; padding:2px; border:solid 1px #000000;"><p>Marital Status</p>
</td>
<td style="vertical-align:top; width:130px; padding:2px; border:solid 1px #000000;"><p>Select list</p>
</td>
<td style="vertical-align:top; width:167px; padding:2px; border:solid 1px #000000;"><p>mst_Patient</p>
</td>
<td style="vertical-align:top; width:243px; padding:2px; border:solid 1px #000000;"><p>MaritalStatus</p>
</td>
<td style="vertical-align:top; width:146px; padding:2px; border:solid 1px #000000;"><br />
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:186px; padding:2px; border:solid 1px #000000;"><p>Registration Date</p>
</td>
<td style="vertical-align:top; width:130px; padding:2px; border:solid 1px #000000;"><br />
</td>
<td style="vertical-align:top; width:167px; padding:2px; border:solid 1px #000000;"><p>mst_Patient</p>
</td>
<td style="vertical-align:top; width:243px; padding:2px; border:solid 1px #000000;"><p>RegistrationDate</p>
</td>
<td style="vertical-align:top; width:146px; padding:2px; border:solid 1px #000000;"><p>Yes</p>
</td>
</tr>
</table>
</div>
<p>&nbsp;</p>
<p><span style="font-weight: bold;">List of all registration form pre-defined fields</span></p>
<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; background-color:#99ccff; padding:0px; border:solid 1px #000000;"><p><span style="font-weight: bold;">Pre-defined Field Name</span></p>
</td>
<td style="vertical-align:top; width:172px; height:19px; background-color:#99ccff; padding:0px; border:solid 1px #000000;"><p><span style="font-weight: bold;">PDFTableName</span></p>
</td>
<td style="vertical-align:top; width:128px; height:19px; background-color:#99ccff; padding:0px; border:solid 1px #000000;"><p><span style="font-weight: bold;">Control Type</span></p>
</td>
<td style="vertical-align:top; width:130px; height:19px; background-color:#99ccff; padding:0px; border:solid 1px #000000;"><p><span style="font-weight: bold;">BindTable</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>Village_Town_City</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>Dtl_PatientContacts</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Select list</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>Mst_Village</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>District_County_Ward</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>Dtl_PatientContacts</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Select list</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>Mst_District</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>Province_State</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>Dtl_patientContacts</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Select list</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>Mst_Province</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>Parish </p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>Home_based_care</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>PatientTelephonenumber</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>TreatmentSupportTelNumber</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>Landmark</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>Sublocation</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>NearestHCenter</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>LocalCouncil</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>Mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>Address</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>Mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>EmergContactName</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>dtl_patientContacts</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>EmergContactRelation</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>dtl_patientContacts</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Select list</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_decode</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>EmergContactPhone</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>dtl_patientContacts</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>EmergContactAddress</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>dtl_patientContacts</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>Phone</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Text box</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>NULL</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>TreatmentSupporterVillageTownCity</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>Dtl_PatientContacts</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Select list</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>Mst_Village</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>TreatmentSupporterDistrictCountyWar</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>Dtl_PatientContacts</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Select list</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>Mst_ward</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>TreatmentSupporterProvinceState</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>Dtl_PatientContacts</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Select list</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_Province</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>CareEntryPoint</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Select list</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_lptf</p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:272px; height:19px; padding:0px; border:solid 1px #000000;"><p>ClinicalTeamLeader</p>
</td>
<td style="vertical-align:top; width:172px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_patient</p>
</td>
<td style="vertical-align:top; width:128px; height:19px; padding:0px; border:solid 1px #000000;"><p>Select list</p>
</td>
<td style="vertical-align:top; width:130px; height:19px; padding:0px; border:solid 1px #000000;"><p>mst_employee</p>
</td>
</tr>
</table>
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